PITCHING UNDER STRES

Indians seek ways to reduce arm injuries

Wednesday, September 24,
2003

Story John Mangels

PLAIN DEALER REPORTER

Birmingham, Ala. - There's a momentary pause before the violence starts, a fleeting second of repose when a major league pitcher stops to gather himself, his eyes lowered and his hands clasped in front of his chest as if in prayer. That's when you can see it.

Look close, on the inside crook of his throwing arm.

Right below the shirtsleeve, etched in the smooth skin where the elbow bends, is Dr. James Andrews' signature.

The famous orthopedic surgeon can spot his mark on pitchers from just about any major league team. When he picked up his newspaper the day after John Smoltz set a National League record last September for games saved, there it was - a thin, pale stripe barely visible in the photo as the Atlanta hurler's arm began its speed-blurred arc toward the plate.

Just this summer, young pitchers Brian Tallet of the Indians, A.J. Burnett of the Florida Marlins and Brian Moehler of the Houston Astros gained the same distinctive battle wounds, joining the 150 or so professional and amateur ballplayers whose shredded elbow ligaments Andrews replaces each year.

The players' scars are roughly V-shaped, but they might as well be dollar signs. Pitching injuries cost Major League Baseball tens of millions a year in disability payments, not to mention the untold price of games not won and seats not filled because a big-name starter is out for a season, if not a career.

Until recently, most teams considered damaged elbows and shoulders part of the cost of business, an inevitable consequence of repeatedly flinging a baseball at speeds that would earn a motorist a hefty ticket.

"If you throw baseballs long enough," Andrews says, "sooner or later you're probably going to wind up in somebody's operating room, and maybe more than once."

But the Indians and a few other progressive-minded teams are challenging that notion, aided by Andrews himself, who wouldn't mind losing some of his surgical business if science can help young arms avoid, or at least postpone, the scalpel.

At the American Sports Medicine Institute that Andrews founded in Birmingham, researchers have focused on understanding what happens to shoulders and elbows during the brutality of pitching. Using some unconventional resources - like the computer wizardry behind "The Matrix Reloaded" and dozens of medical specimens better suited to "The Texas Chainsaw Massacre" - ASMI scientists believe they know what separates injury-free pitchers from injury-prone ones.

"We've spent 30 years trying to figure out how to fix injuries," Andrews says in his soft Southern drawl. "We've sort of got the cart before the horse. What we're trying to do with our research institute is devote more energy and research money to try to figure out how to prevent injuries."

The cost of injuries

Let's say you've decided to plunk down $283,600 for a sleek new Lamborghini Murcielago, one of the fastest sports cars on the planet. It lives up to its 205 mph promise, and for a while, no street racer in the neighborhood can touch you.

But your shifting technique leaves something to be desired; without realizing it, you are riding the clutch. Eventually, your Italian-bred dream machine ends up in the mechanic's bay and you are stuck paying your car note, a whopping insurance premium, and a repair bill that will put your mechanic's kid through college, all with no wheels to show for it.

No one would mistake Bob Wickman for a Lamborghini, but the point is the same. The Indians are paying the beefy 34-year-old right-hander $16 million over three years to smoke opposing batters. Last December, a year after All-Star Wickman joined the team, the ligament that had stabilized his right elbow during more than 20 years of pitching decided it had had enough, and split.

After surgery and eight months of rehabilitation, Wickman has done some limited throwing with the Indians' minor-league teams. But that does nothing for the parent club. The disability insurance money the Tribe collects on Wickman - one of just a handful of policies it can afford to maintain on its biggest-name players - probably will end up covering only the cost of the premiums.

Meanwhile, Wickman's replacement as closer, Danys Baez, struggled all season before finally losing the job in August.

When it comes to injuries, the Indians "are one of the worst" compared to the number and severity of other teams', admits General Manager Mark Shapiro. Indians pitchers missed a combined total of 571 days last season because of injuries.

"Right now, it doesn't affect us," Shapiro says. "But if you're trying to be a championship team, every single day one of those players is on the disabled list is impacting your ability. It could be the pennant."

Although injuries are only one factor, no Tribe pitcher has won 20 games or more in a season since Gaylord Perry did it in 1974.

Competition aside, pitching injuries are simply bad for business, and the Indians these days are nothing if not a business-minded team. Here's the seemingly unsolvable equation they and other middle- and small-market ball clubs face:

Team revenues have shrunk. Player salaries have increased. With the impact of 9/11 and the economy in the tank, insurance is much harder and costlier to get, especially for players with a history of getting hurt. The number of injuries is increasing. The duration of injuries is lengthening. Pitchers get hurt more often than any other players and take longer to recover. Because they tend to be the highest-paid players on a team, pitchers account for an inordinate share of disability payouts. And the talent pool of good pitchers is small, so they're hard to replace.

Whoa. How do you climb out of that quicksand? As the Indians and a couple of other teams have realized, the answer is not to get stuck in the first place. The solution is prevention, or at least postponement. But first, someone had to figure out what exactly to prevent.

A painful ballet

Slow a pitcher's motion down to a molasses crawl and you can see elements of a hurdler's high kick, a tightrope walker's balance, a contortionist's freakish bends and a brawler's roundhouse swing.

Revved back up to real time, it has the sudden, explosive fury of a cobra's strike. The pitcher's shoulder rotates so fast that, if it could move in a full circle like a clock hand, it would complete 21 revolutions in a second. Throwing a baseball is the quickest known motion the human body can make.

Packed into the few seconds it takes to launch the ball toward the plate are a ballet's worth of limb twists, body turns and weight shifts. Biomechanics specialists call this the "kinetic chain," a fancy phrase that really means the transfer of energy from the pitcher's legs and trunk through the shoulder and arm to accelerate the 5-ounce baseball.

There are six links in the chain, six distinct phases of the pitch - windup, stride, arm cocking, arm acceleration, arm deceleration, and follow-through. Each phase has its own unique set of motions and resulting forces on the body.

To reduce the chance of injury and boost the ball's speed as it leaves his hand, the pitcher must perfectly time this sequence of moves. He also must make sure that legs, pelvis, torso, shoulder, elbow, forearm and wrist are kept properly oriented in space, and in relation to each other.

He can't consciously think about any of this, though. It has to be automatic, instinctive. His focus must be on selecting the right pitch, putting the ball in the right location at the plate, keeping a runner from stealing.

"It's a lot more intricate than a lot of people think," says Jeremy Loftice, a pitcher for Louisiana State University's 2000 national championship team who's now clinical research coordinator at the Alabama sports medicine center.

Even if a pitcher's form is perfect, he can't escape the ferocious toll that throwing dozens of times a day, in dozens of games a year, season after season, exacts on the arm.

"It's the most unnatural thing you can do with your body," says Tallet, the Indians pitcher whose elbow ligament Andrews replaced last month. The lanky left-hander has pitched since the age of 9, and occasionally threw 130 pitches a game in college, although he had a week's rest between games and the season was shorter than in the major leagues.

Like weightlifting, swinging a sledgehammer or any other stressful, repetitive action, pitching causes microscopic tears in muscles, tendons and ligaments. It also bends joints at extreme angles and rubs the surfaces of bones against each other in ways that nature didn't intend. A lot of tugging, a lot of grinding. Load a yard's worth of fertilizer sacks at the garden center or lug your suitcase through a few airports and you'll get the idea.

Given a few days of rest, the body can repair small injuries. But push too hard or too soon and the damage becomes permanent. Over the years, muscle tears accumulate to become cracks, and cracks widen to clefts. Bone-protecting cartilage wears out. Something has to give.

"You're basically breaking yourself down at a faster rate than you're letting yourself heal," explains Glenn Fleisig, the Birmingham center's chairman of research. Fleisig stopped playing baseball in high school but knows more about the pitching motion than most pitchers.

Bad pitching mechanics make this breakdown happen much sooner. So does throwing an excessive number of pitches - more than 50 in a game for 9- to 10-year-olds, and generally above 120 for a professional player. Certain kinds of pitches also accelerate the injury process, notably the curveball and slider, which require extra force at the shoulder and elbow to impart the proper spin to the ball.

How do researchers know all this? How much can a joint take before it fails? And what's the "right" way to pitch? That's where the cameras, computers and cadavers come in.

I see dead people

What would be ideal, really, for a biomechanics researcher is if a pitcher's skin could suddenly disappear, like those ghostly swashbucklers in the "Pirates of the Caribbean" movie who suddenly morph into walking skeletons.

That way, you could watch the elbow or shoulder in action. You could see the ulnar collateral ligament stretch tight as a violin string as it strives to keep a pitcher's forearm from snapping free of his upper arm when he cocks it back to throw. You could see the thick tendons of the rotator cuff rub again and again on a ridge of bone as the shoulder rotates forward to accelerate the arm. You could see the rounded ends of the bones in the elbow and shoulder joints jammed together with a force greater than the pitcher's weight as the body fights to keep the arm from flying off into space.

You can't, of course, see that in a living human being. That's where some of the dear departed who've donated their bodies to science, and some of the best pitchers in the country, have combined forces to help the national pastime.

Every so often at the American Sports Medicine Institute, a package truck drops off a special delivery. Packed in dry ice are neatly removed and carefully preserved shoulders and elbows from people who have agreed their remains can be used for medical research.

Biomedical engineer Nigel Zheng supervises ASMI's cadaver studies. Using machines that apply very precise, measured amounts of force or torque, Zheng and his colleagues - there is no polite way to put this - pull and twist the joints until they come apart.

This kind of work, which also helps test the effectiveness of surgical repairs, has shown, for instance, that the thin, rubbery ulnar collateral ligament (UCL) on the inside of the elbow can take about 140 pounds of force before it snaps. At the part of the pitching motion where the arm is cocked farthest back, preparing to swing forward and release the ball, researchers have found that the UCL is loaded almost to its breaking point on every single pitch. And that's just one joint.

Only a pitcher who has extraordinarily good form - meaning good biomechanics - can minimize the wear and tear on his arm by reducing unnecessary force on joints. So ASMI scientists set out to understand what good pitching form is.

Since 1989, more than 800 pitchers from youth league teams to college and pro clubs have come to the institute's gymlike biomechanics lab to be tested. Of those, the researchers have focused on the biomechanics of 50 elite pitchers who were injury-free for a year or more and able to throw at least 84 mph.

The pitchers wriggle into body-hugging Spandex togs, then try not to sweat while researchers tape 16 marble-sized reflective plastic balls to each of their major joints to mark its position.

Standing on a makeshift mound, the guinea-pig pitchers fire fastballs into a circular target 60 feet 6 inches away, just like in a real ballpark. Six cameras track and record the location of the reflective markers as the pitcher throws. It's the same equipment and process that helps computer animators capture human motions for movies like "Final Fantasy" and "Batman Forever," and for video games like Mortal Kombat and NBA Live.

The digitized information shows up on the lab's computer screens as a stick figure, a first-grader's rendering of Roger Clemens. By studying the computer frames and ultra-slow-motion video footage, Fleisig and colleagues have learned volumes about what throwing movements and body positions healthy pitchers have in common. The results are compiled in the institute's pitching database, which includes Clemens, Jack McDowell, Al Leiter and Denny Neagle.

For example, when a pitcher lifts his leg and lunges toward the plate in preparation to throw, his stride length should be 80 percent of his height. His front foot should touch down directly in line with his back foot, give or take 2 inches left or right, and his knee should flex about 135 degrees. When his arm cocks, the elbow should be at a right angle to his body, and his forearm should bend rearward behind his ear no more than 180 degrees.

Until recently, the nonprofit ASMI had focused on getting its research findings to doctors, physical therapists and coaches of youth baseball teams, in hopes of heading off injuries in young players. About two years ago, the institute decided to expand its prevention efforts to Major League Baseball. Coincidentally, Oakland Athletics pitching guru Rick Peterson had the same idea.

Peterson got to know Andrews and ASMI during his stint as pitching coach of the Chicago White Sox's Birmingham Class AA minor league team from 1989 to '91. A psychology major in college, Peterson is legendary for his success in tapping young pitchers' potentials, using everything from Eastern meditation techniques to teaching them to throw with their eyes closed. As a coach with the Indians' Buffalo Bisons Class AAA farm team, he once suggested that pitcher John Farrell wear his cap bill lower to look tougher to opposing batters and serve as a mental reminder to pitch aggressively.

At Oakland, Peterson was searching for ways to reduce injuries and increase the efficiency of his pitchers. He brought starters Tim Hudson, Barry Zito and Mark Mulder to Birmingham to have their throwing motions analyzed and compared to ASMI's database of healthy, elite pitchers. The results are in a detailed report that explains the good and bad aspects of a pitcher's technique and how he compares with ideal standards.

With the exception of Mulder, who's had back and hip problems, the A's pitchers have stayed healthy. Zito won the American League Cy Young Award last year, and the pitching staff had the lowest earned-run average in the league. Peterson praised ASMI's evaluation techniques on a promotional video the institute sent to all 30 major league teams.

Curiously, besides Oakland, only Cleveland and the Boston Red Sox have announced that they'll take advantage of the lab's work. It's no coincidence that the Indians, A's and Red Sox each have young general managers with systematic, sometimes unconventional approaches to running their teams.

Send in the clones

Some of the skepticism about ASMI's methods may come from baseball's traditionalists, the coaches and general managers who were players or have spent their careers around players and no doubt wonder what the heck some egghead in a lab coat can know about throwing heat.

"There's an old-school attitude and a new technological attitude," says ASMI executive director Gil Etheridge. Most teams "don't have enough confidence in the science. We've just got to prove over time that we're right."

There also may be resistance from pitchers themselves, who are notoriously skittish about letting someone monkey around with the way they throw. Major league pitchers also worry about losing their edge, about becoming "clones." Pitching is the art of deception, and every pitcher believes he does something unique that fools a batter into swinging early, late or not at all. Make him pitch like someone else - even if it is with the noble goal of reducing the chance he'll get hurt - and he'll probably say no thanks.

"I throw a certain way," says former Indians starter Brian Anderson, who was traded last month to Kansas City. "A little bit of adjustment is OK." But a wholesale change? Anderson is skeptical. "Maybe I'll be able to throw until I'm 50, but I won't get anybody out," he says. And what good is that?

A pitching coach can make the difference between a player's embracing or rejecting preventive biomechanics changes, Peterson says. His job is to translate, and in some ways to censor, giving the pitcher only what he needs to keep throwing well but helping him avoid distractions.

"When you were learning to ride a bike, did anyone tell you that the ball of your foot had to be positioned exactly over the pedal, or that your thumb should be on the bottom of the handgrip and your other fingers above it?" Peterson says. The details of a pitcher's biomechanics analysis "are none of their business. You don't need to know how to build a car to drive it."

The Indians executives know they'll have to confront pitchers' concerns, but they believe strongly enough in the value of biomechanics analysis as a preventive measure that they're planning a "field trip" to Birmingham this fall so managers can learn the ASMI way.

The biggest disciple is former Indians pitcher and Peterson pupil Farrell, who's now the Tribe's director of player development. Although some of the major league team's pitchers may undergo evaluation, Farrell sees the biggest potential at the Class AA level, where young players are still developing. The Indians may also check the mechanics of some pitching prospects before they're signed.

When instituting the new system, "the relationship and rapport between coach and player is important," Farrell says. "We have to be careful not to institute a blanket approach - it's got to be customized to each player. We don't want picture-perfect pitchers who won't get someone out."

Farrell, though, knows better than anyone the value of injury prevention. He spent parts of five years as an Indian, but his career was marred by two operations to repair his blown-out elbow ligament.

"It's not a matter of 'if,' it's 'when' a pitcher is going to have surgery," Farrell says. "Something's bound to wear out and give. We're trying to lengthen that 'when.' "

To read the entire Rethinking the Game Plan series online, go to:www.cleveland.com/gameplan